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  1. Definition of reimbursement
    payment to the insured for a covered expense or loss experienced by or on behalf of the insured
  2. Definition of fee for service
    a system of payment whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient or by patient's insurance carrier
  3. Definition of Perspective Payment System PPS
    Medicare's system for reimbursing Part A inpatient hospital costs
  4. How is the amount of payment for PPS determined?
    By assigned DRG
  5. Definition of capitation
    common method of paying physicians in HMO
  6. What mandated the use of the perspective payment system for inpatient care?
    Social Security Amendments of 1983
  7. Which organization has primary authority for putting PPS into practice?
    CMS
  8. Definition of DRG
    a system that classifies hospital inpatient cases into categories with similar use of the facility's resources
  9. OBRA 1989 legislated a replacement for the UCR. What was it?
    RBRVS
  10. What key piece of information do you need to classify DRG classification?
    principal diagnosis
  11. Definition of comorbidity
    the presence of more than one disease or disorder that occurs in an individual at the same time
  12. Name of software to identify patients' DRG category
    DRG grouper
  13. What is APC?
    Service classification system designed to explain the amount and type of resources used in an outpatient encounter
  14. What is the coding system when determining APC payment rate?
    CPT
  15. What is RUGs?
    to calculate payments to a skilled nursing facility according to severity and level of care
  16. What is GCPI
    a factor used by Medicare to adjust for variance in operating costs of medical practices located in different parts of the U.S.
  17. What is IPPS?
    Medicare reimburses hospitals for providing inpatient care to beneficiaries with a payment system known as IPPS
  18. What is the average number of days for LTCH?
    25
  19. What is short stay outlier?
    an adjustment to the federal payment rate for LTCH stays that are considerably shorter than the average length of stay for an LTC-DRG
  20. An HHPS payment is dependent on what?
    Oasis
  21. What is a peer review organization? PRO
    Organization typically composed of physicians and other healthcare professionals, paid by the federal government to evaluate the services provided by other practitioners and to monitor the quality of patient care
  22. What is a contractual write off?
    when and agreement exists between the provider and an insurance carrier whereby the provider agrees to accept the payer's allowed fee as payment in full for a particular service or procedure
  23. What is a federal entity that sets guidelines and rules for the entire healthcare industry?
    CMS
  24. A NONPAR that does not accept assignment, what is the most they can charge a patient that Medicare will allow?
    115%
  25. Completion : What organization has the ability to force hospitals to comply with HHS and quality standards?
    Peer review organization (PROs)
  26. Completion: What is capitation?
    common method of paying physicians in HMOs
  27. Completion: What is a DRG?
    a system of classifying hospital inpatient cases into categories with similar use of the facility's resources.
  28. Completion: What is APC?
    a service classification system designed to explain the amount and type of resources used in an outpatient encounter
  29. Completion: What is a contractual write off?
    when an agreement exists between the provider and an insurance carrier whereby the provider agrees to accept the payer's allowed fee as payment in full for a particular service or procedure
Author
areust
ID
187366
Card Set
HIT
Description
AHIT
Updated

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